Determinants of breastfeeding attitudes of mothers in Jordan: A cross-sectional study

Breastfeeding provides the optimal nutrition for an infant. However, breastfeeding practice is on decline globally. Attitude toward breastfeeding may determine the practice. This study aimed to examine postnatal mothers’ attitude to breastfeeding and its determinants. A cross-sectional study was conducted, and data on attitude were collected using the Iowa Infant Feeding Attitude Scale (IIFAS). A convenience sample of 301 postnatal women were recruited from a major referral hospital in Jordan. Data on sociodemographic characteristics, pregnancy and delivery outcomes were collected. SPSS was used to analyze the data and identify the determinants of attitudes to breastfeeding. The mean total attitude score for participants was 65.0 ±7.15, which is close to the upper limit of the neutral attitude range. Factors associated with attitude that is positive to breastfeeding were high income (p = 0.048), pregnancy complications (p = 0.049), delivery complications (p = 0.008), prematurity (p = 0.042), intention to breastfeed (p = 0.002) and willingness to breastfeed (p = 0.005). With binary logistic regression modelling, determinants of attitude positive to breastfeeding were highest income level and willingness to breastfeed exclusively (OR = 14.77, 95%CI = 2.25–99.64 and OR = 3.41, 95%CI = 1.35–8.63 respectively). We conclude that mothers in Jordan have neutral attitude to breastfeeding. Breastfeeding promotion programs and initiatives should target low-income mothers and the general population. Policymakers and health care professionals can use the results of this study to encourage breastfeeding and improve breastfeeding rate in Jordan.

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Unfunded studies
Enter: The author(s) received no specific funding for this work.  3

Introduction:
Breastfeeding enhances bonding between a mother and her infant after birth. It is the most valuable gift a mother can offer to her newborn. The advantages of breastfeeding for both newborns and their mothers are well documented. Increasing the rates of breastfeeding alone can have the potential to save the lives of around a million children under age 5 worldwide [1,2].
Skin to skin contact and breastfeeding immediately after birth have been reported to minimize infant mortality and promote maternal health [3]. In addition, exclusive breast feeding for six months, continued for two years and beyond with the provision of safe and appropriate complementary foods are the most important strategies for promoting child survival and health [4]. However, the benefits of breastfeeding are underestimated, and the proportion of mothers who breastfeed their newborns is way below the recommended levels globally and Jordan is not an exception [5,6].
What determines women's attitude towards breastfeeding? A large body of research have indicated various factors that influence women's attitude to breastfeeding, including age, education, family income, employment and previous experience with breastfeeding [8,10,[25][26][27]. In addition, cesarean section delivery, preterm delivery, infant health status and neonatal intensive care unit NICU admission were reported to impact mothers' attitude to breastfeeding in Jordan [19,25].
However, there is scarcity in research addressing factors that determine mothers' attitude toward breastfeeding in Jordan. Hence, the purpose of this study was to assess mothers' attitude toward breastfeeding, and to explore factors that may influence and predict this attitude among mothers.

Study Design and setting
This observational cross-sectional, hospital-based study was conducted to examine the attitudes of mothers in Jordan toward breastfeeding. Postnatal mothers were recruited from the maternity ward of a referral tertiary teaching hospital in Amman, the Capital city of Jordan, during the study period January 2020 to May 2021. This hospital is an accredited Baby-friendly hospital since June 2018 and has approximately 3000 births annually.

COVID lockdown and responsive adjustments at the study setting
Despite the hospital's high patient population, data collection was time-consuming because of the Covid-19 epidemic. During the pandemic, hospital admission and patient access were regularly limited when infected patients or personnel were reported.

Population and Sample
The target population for the current study was postnatal women in the maternity ward. The sample size was calculated using a Confidence Interval of 95% and a Margin of Error of 5%. A sample size of at least 290 was found to be adequate.

Study Instrument
The questionnaire for this study consisted of four parts. Iowa Infant Feeding Attitude Scale (IIFAS) [28], a validated tool used to measure attitudes of mothers toward infant feeding. It includes 17 items with a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). Eight statements indicate positive attitude toward breastfeeding and nine statements indicate positive attitude toward formula feeding, the latter were reverse-scored before calculating the total scores of all items. An example for attitude is: "Formula-feeding is more convenient than breastfeeding", and "Breastfeeding increases mother-infant bonding". The total IIFAS score can range from 17 to 85 with higher scores reflecting more positive attitude towards breastfeeding. The total IIFAS is further classified as positive to breastfeeding (a score of 70 -85), neutral (a score of 49 -69) and positive to formula feeding (a score of 17-48). The researcher used a validated Arabic version of the IIFAS was used after permission from the author [29]. The tool was pilot tested on 30 participants to check for clarity, response time, any potential problems with the questionnaire in addition to reliability. Cronbach's alpha analysis revealed good reliability of the IIFAS, with coefficient equals to 0.72. No major changes were made based on the pilot test results. 6 Additionally, sociodemographic characteristics of mothers, and pregnancy and delivery information which includes mode of delivery, gestational age, the presence of complications during pregnancy or delivery, admission of the baby to neonatal intensive care unit (NICU), and receiving antenatal counseling for breastfeeding were all collected. The fourth aspect consisted of five questions to assess breastfeeding practices, which was created by the researcher abased on the Centers for Disease Control and Prevention (CDC) guidelines [28]. These include items about intention to breastfeed, willingness to breastfeed exclusively, receiving counselling for breastfeeding and time of initiation of breastfeeding.

Data collection procedure
Research team, were trained in interviewing procedures, collected data from postpartum mothers who entered the hospital's maternity ward after delivery. Data collection took place in the period between January 2020 and May 2021, using a structured interviewer-administered questionnaire. Despite the high volume of patients in this hospital, data collection required a long time, because of the Covid-19 pandemic restrictions.
The research team approached mothers after delivery, introduced themselves, and offered them the opportunity to participate in the research study. Those willing to participate were given further details and a verbal consent was obtained. Medical students were responsible for data collection, where they asked mothers questions and mothers responded. Medical students entered the answers electronically. The response rate was 95% with 301 mothers completed the questionnaires to collect sociodemographic information and the IIFAS questions. Data related to the pregnancy and delivery outcomes were collected from the medical record. Each mother's electronic medical record was searched for information pertaining to the pregnancy and birth outcomes. Every questionnaire was checked for completeness before medical students left the 7 ward. During data collection, appropriate infection prevention control measures and principles relevant to COVID-19 were also addressed.

Ethical Considerations
The ethical committee (IRB) in the University of Jordan Hospital approved this study (no. 2019-229). All study protocols complied with the guidelines established by the institution's committee on research ethics. Participation in the study was voluntary, and verbal consent was obtained from participating mothers. Mothers were assured that the service they receive would not be affected by their decision to participate in the study. Data obtained were kept confidential, and were used strictly for the purpose of this research. Confidentiality of the data was preserved, data were stored in password-protected files in the computers of the research team, and were used only for the purpose of this research.

Analysis
The collected data were examined for completeness and consistency, and then data was cleaned. Statistical analysis were performed using Statistical Package for Social Sciences (SPSS) version 21 [29]. Descriptive statistics were used to summarize the sociodemographic personal characteristics, pregnancy and delivery variables, and infant breastfeeding-related variables. In addition, the mean and standard deviation for individual items of IIFAS, and total score for the attitude toward breastfeeding for each respondent were calculated. To determine the specific factors that influence breastfeeding attitude among participating mothers in the current study, independent t-test and one-way ANOVA statistical tests were performed. Additionally, multiple linear regression was used to detect predictors of attitude of mothers toward infant feeding. The results were expressed as adjusted odds ratio (AOR) with 95% confidence intervals (CI) and pvalues. P-values <0.05 were considered statistically significant. 8

Results
Data collected from 301 mothers after delivery were included in the analysis. Table 1 demonstrates the sociodemographic characteristics of participants in addition to pregnancy and delivery information.
More than 40%of the study population were 30 years of age or older and more than 70% had up to three children (including the recently delivered infant). Over 75% of participants had a university degree or higher. A large proportion of the sample were employed (43.2%). More than 60% of mothers had a monthly family income of 450 Jordan Dinar or less, and the vast majority (93%) had health insurance. The most common pregnancy complication among mothers was gestational diabetes (16%), and 26% had preterm deliveries constitutes 26% of infants. More than half of all deliveries were by a cesarean section (56.2%) and 18% of infants were admitted to NICU (Table 1). Around 43% of mothers initiated breastfeeding during the first day after firth, while 28.6% did not initiate breastfeeding before discharge (Table 2). The attitude of participants to infant feeding, as measured using the IIFAS after delivery, are demonstrated in Table 3. The statements with the highest mean were "Breastfeeding increases mother-infant bonding" and "Babies fed breast milk are healthier". The statements with the lowest means were "Mothers who occasionally drinks alcohol should not breastfeed" and "Women should not breastfeed in public places". Overall mean attitude toward infant feeding was 3.95 ± 1.04 (out of 5) and the overall total (summed) attitude score for participants was 65±7.15 (out of 85). This indicates a neutral postnatal attitude to breastfeeding, with only 24.3% of mothers demonstrating positive attitude to breastfeeding after childbirth (total attitude score ≥70 out of 85) ( Table 3).  Table 4 displays the relationship between mother's total attitude toward breastfeeding and personal characteristics, pregnancy and delivery variables, using t-test and ANOVA. Results show that attitude toward breastfeeding was significantly higher among women with higher income (p = 0.048), who had pregnancy complications (p = 0.049), with delivery complications (p = 0.008), who had preterm infants (p = 0.042), who intended to breastfeed (p = 0.002) and who were willing to breastfeed exclusively (p = 0.005). of variance in the attitude toward infant feeding score of mothers who gave birth in the current study (Table 5).

Discussion
The rates of breastfeeding are on decline globally including Jordan. Mothers' attitude toward breastfeeding is a vital factor that influences breastfeeding practice. This study aimed to assess mothers' attitude toward breastfeeding in Jordan, and to identify the determinants and predictors of this attitude. Results of this study exhibit that a small proportion (24.3%) of mothers in Jordan have positive attitude toward breastfeeding. This is high compared to 9.2% having positive attitude to breastfeeding in Lebanon and Qatar [23], but considerably lower than 72% having positive attitude in Jordan in 2020 [24], and 55% in India [30].
The total attitude score in this study was 65.0 ± 7.15, which is very similar to total IIFAS score (63.5 ± 4.67) reported previously among Jordanian mothers [19]. This score is low compared to the very positive attitude with a total score of 81.39 ± 8.35 in Jeddah, Saudi Arabia [25], and to 69.76 ± 7.75 in Spain. On the other hand, lower total scores were reported in Poland (63.12 ± 14 7.34), in Saudi Arabia (59.6 ± 7.3) [31], and neutral attitude to breastfeeding (30 out of 50) in Fiji [8].
Findings of this study pointed out multiple sociodemographic characteristics and delivery characteristics that were associated with mother's attitudes to infant feeding. In accordance with other studies, socioeconomic status and particularly higher income, was associated with more positive attitude to breastfeeding in Saudi Arabia [25], Fiji [8] and Lebanon and Qatar [23]. In fact, higher family income continued to be a predictor of more positive attitude to breastfeeding, even after controlling for all other variables. This indicates the multifaceted nature of the attitude toward breastfeeding, involving a wide array of social norms, culture and health care environment factors.
Interestingly, mothers who had pregnancy and delivery complications had significantly more positive attitude to breastfeeding. Similarly, positive attitude to breastfeeding was associated with preterm delivery in this study. This contradicts earlier findings, where mothers of preterm infants were less likely to have positive attitude to breastfeeding [19], while other studies reported no association [23][24][25]. Our finding may reflect the psychological response of mothers in their effort to compensate their newborns with breastfeeding to support their growth with love and care. In addition, our results indicated that NICU admission did not negatively influence postpartum attitude to breastfeeding as expected, which implies that NICU of the baby was not a barrier to breastfeeding among mothers in this study. Although admission to NICU was associated with a significant delay in the initiation of breastfeeding to second or third day after childbirth, it did not prevent initiation. This may be because this hospital is baby-friendly, and the healthcare providers do encourage and support mothers to initiate breastfeeding after birth. 15 Despite the fact that no association was found in this study between working status or employment and attitude to breastfeeding, other studies reported a negative association, where employment was a barrier to breastfeeding [7,13,[23][24][25][26][27]32]. According to Al Tamimi et.al., 30% of the mothers in their study in Jordan, attributed premature cessation of breastfeeding to work [27]. In addition, Khasawneh et.al. indicated the short maternity leave as a prominent reason for nonexclusive feeding in Jordan [32]. The majority of mothers in the current study believed that mothers who were going back to their employment after childbirth, should choose formula feeding. Nevertheless, there was no difference in the mean attitude score between mothers who work and those who do not work, nor in their time of initiation of breastfeeding before discharge from hospital. This may suggest the more or less breastfeeding-friendly behavior that mothers perceive in many workplaces in Jordan.
We did not find any difference between mothers who received prenatal or postnatal counselling about breastfeeding and those who did not receive any counselling. In addition, no association was found between attitude and early initiation of breastfeeding. This is in line with findings of Khasawneh et.al., where counselling about breastfeeding by healthcare providers did not influence breastfeeding practice [24]. This may suggest that education and providing information about breastfeeding during pregnancy or just after delivery is not enough to influence mothers' attitude to breastfeeding.
This study demonstrated that mothers with intention to breastfeed and those who are willing to breastfeed exclusively had more positive attitude to breastfeeding. In fact, intention to breastfeed remained as a significant predictor even after controlling for other variables. This aligns with the findings from a number of studies in the literature [7,23,24], where associations were reported between planning and intending to breastfeed and attitude. Intention to breastfeed echoes mothers' attitude to breastfeeding, which depends on the deeply ingrained cultural and 16 social values that mothers have acquired through their life experiences. Therefore, inspiring mothers to breastfeed should be a component of the early stages of an antenatal care program or during planning for pregnancy.
To shape attitude to breastfeeding in mothers , it is essential to build more positive attitude to breastfeeding among husbands, mothers, mothers in law and friends of pregnant women [33]. Friends and family, among others in the community have a critical role in supporting, assisting, encouraging and motivating mothers to initiate and continue breastfeeding after childbirth, and their own attitudes to breastfeeding positively influence mothers' breastfeeding decisions and practices. They can effectively help mothers conquer barriers that may arise along the breastfeeding journey.
This study is the first to explore postnatal mothers' attitudes to breastfeeding in Jordan in addition to the influence of validated pregnancy and delivery outcomes on this attitude. Results of this study added insight to the evolving body of literature about mothers' breastfeeding attitudes in Jordan.

Limitations
Nevertheless, there are some limitations of this study. First, the main challenge was that data collection started just before Covid-19 pandemic, which interrupted and delayed the process of data collection. There was the lock down initially, followed by limitation to admissions to the wards during that period. Additionally, temporary closure of the ward when cases were identified limited access of the research team for data collection. Thus, the sample size is less than planned beforehand. Second, results may not be generalizable to mothers in Jordan, since our sample did not include mothers with no health insurance who gave birth in private hospitals. In addition, the study was carried out in a teaching hospital, which is certified as a baby-friendly hospital.
Therefore, results may have restricted generalizability to the population of mothers in Jordan who receive services in non-baby-friendly facilities. Third, the interviewer-administered way of data collection for the attitude, may have resulted in social desirability bias in responses, despite the training provided for the interviewers to reduce this bias.

Recommendations
Future research may explore women's attitudes before pregnancy, during pregnancy, and after delivery in order to investigate the effect of pregnancy and delivery experience on breastfeeding attitude. More qualitative studies can be of great benefit in exploring breastfeeding attitudes in the population in Jordan.
There is an immediate need for Interventions in Jordan to improve the rate of breastfeeding. Public policies can be implemented to increase the availability of designated breastfeeding places in workplaces, public places, parks, shopping malls, restaurants and health care facilities that are breastfeeding-friendly, prepared with a suitable place for breastfeeding.
Policies and laws on marketing formula milk and breastmilk substitutes, paid maternity leave, availability of day care facilities, breastfeeding breaks for employed mothers, should all be enforced. Workplaces should encourage mothers to breastfeed their infants, and even reward them for adhering to this practice. Since the majority of women in Jordan give birth in private hospitals, more private hospitals better be encouraged to join the Baby Friendly Hospitals initiative. Interventions are specially needed to positively impact attitude to breastfeeding in low income communities, targeting women, their husbands, families and friends. Their support and encouragement is necessary for mothers to start and continue breastfeeding. 18 Health care students in all disciplines must be educated on breastfeeding. In addition, public education is essential to support and encourage woman's decision to breastfeed. To achieve that, initiatives must clearly communicate the benefits and importance of breastfeeding to the people [34], against the strong marketing for breastmilk substitutes by the companies.
Well-designed interventions for improving breastfeeding counselling by health care providers after birth is vital. Maternity nurses can be very effective in educating, supporting and encouraging women to breastfeed. Special counselling provided to mothers who had cesarean delivery and who have newborns in the NICU is essential. Policies and laws on marketing formula milk and breastmilk substitutes, paid maternity leave, availability of day care facilities, breastfeeding breaks for employed mothers, should all be enforced. Workplaces should encourage mothers to breastfeed their infants, and even reward them for adhering to this practice.

Conclusion
To conclude, the determinants of mothers' attitude to breastfeeding was explored, in an effort to improve the rate of breastfeeding in Jordan. This study found that the mothers in Jordan have neutral attitude toward breastfeeding. In addition, it revealed the need for adopting various strategies for stimulating more positive attitude to breastfeeding on the population level, and especially people with low income, to optimize breastfeeding rates in Jordan. Healthcare professionals at all level of the health care system must play a vital role in promoting breastfeeding. Policy level interventions related to workplaces are extremely important in order to minimize the impact of employment as a barrier breastfeeding. Findings of this study can be instrumental for health care providers and policy makers in Jordan in their intentional efforts to promote breastfeeding on the population level.